Effects of levosimendan in patients with left ventricular hypertrophy undergoing aortic valve replacement.

BACKGROUND: Left ventricular hypertrophy is associated with adverse outcomes, including death, during cardiac surgery. This may be facilitated by an increased oxygen demand and diastolic dysfunction. Levosimendan augments haemodynamics without further oxygen consumption and improves echocardiographic indices of diastolic dysfunction. This study aimed to describe the haemodynamic effects of short-term pre- and intra-operative levosimendan infusion including advanced echocardiographic measures of diastolic and systolic heart function. METHODS: The study was randomised, double-blinded and placebo-controlled performed at a single-centre university hospital. Patients with left ventricular hypertrophy and ejection fraction > 45% scheduled for single procedure aortic valve replacement were included and randomised to infusion of either levosimendan 0.1 µg/kg/min or placebo from 4 h before anaesthesia to the end of surgery. Outcome measures were echocardiographic indices of left ventricular diastolic function: E/e' (primary endpoint), e', e'/a' and indices of systolic function: longitudinal strain, ejection fraction and s'. Patients were followed until 6 months after surgery. In addition, invasive haemodynamic measures were obtained perioperatively. RESULTS: The trial was prematurely terminated due to an overall high incidence of post-operative atrial fibrillation (15/20, P = 0.002) after inclusion of 20 patients. The relative decrease in perioperative cardiac index was lower (P = 0.016) in the levosimendan group. There was no difference in E/e', and similar results were found for all measures of systolic function. CONCLUSION: Short-term levosimendan caused a transient relative increase in cardiac index, but no effect was seen on the first post-operative day and up to 6 months post-operatively with indices of systolic and diastolic heart function.

Extracorporeal membrane oxygenation in adult patients with severe acute respiratory failure.

BACKGROUND: A group of patients with severe acute respiratory distress syndrome (ARDS) is resistant to advanced respiratory therapy. In these patients, extracorporeal membrane oxygenation (ECMO) can be used as a rescue therapy. This study presents 14 years of experience from a Scandinavian ECMO centre. The aim of the study is to present outcome results and to investigate whether or not simplified acute physiology score II (SAPS-II), sequential organ failure assessment (SOFA) and/or Murray scores can be used to predict patients' outcome. METHODS: In a prospective observational study, we collected data from ECMO patients from January 1997 to March 2011. The treatment was based mainly on venous-venous ECMO and centrifugal pumps. Patients were retrieved from Denmark plus a number from Sweden and Norway. The inclusion criteria were the classical criteria until November 2009 (n = 100), after which the new Extracorporeal Life Support Organisation criteria (n = 24) were used. RESULTS: One hundred and twenty-four patients were enrolled with median age 45 (range 16-67) years. The median Murray score was 3.7 (2.5-4.0). One hundred and six (85%) of the patients were retrieved from referring hospitals on ECMO. The median duration of the ECMO runs was 215 (1-578) h. Ninety-seven (78%) of the patients could be weaned from ECMO. A total of 88 (71%) were discharged alive to the referring hospitals. High SAPS-II, SOFA and Murray scores were associated with a high mortality. CONCLUSION: Patients with severe ARDS have a favourable outcome when treated with ECMO and when an ECMO retrieval team establishes the ECMO treatment at the referring hospital. SAPS-II, SOFA and Murray scores predicted the outcome.

[Esophageal perforations]. / Esophagusperforationer.

An oesophageal perforation is a serious condition with high morbidity and mortality. During the latest decades an increased number of traumatic perforations as well as wide use of endoscopic procedures have increased the incidence of oesophageal perforation. An early diagnosis and treatment is important for the prognosis. Cervical and selected thoracic perforations can be treated conservatively although the majority should be operated. Primary closure can be performed if done before 24 hours have elapsed, while later treatment is controversial. Drainage of the mediastinum and pleural space, as well as diversion of saliva and gastric content is important. The literature is reviewed in relation to etiology, diagnosis, treatment and prognosis.

Intra-aortic balloon counterpulsation in Denmark 1988-1991. Early results and complications.

During the years 1988-1991 6319 patients underwent cardiac surgical procedures in Denmark. In 183 patients (2.9%) with left ventricular failure intra-aortic balloon counterpulsation (IABP) was used. Four percent of the IABP were placed preoperatively, 86% intraoperatively and 10% postoperatively. Severe complications occurred in 16 patients (8.7%) and were mainly vascular due to limb ischemia. The incidence of complications was independent of the duration of balloon pumping. Sixty percent of the patients were weaned from IABP. The 30-day mortality rate was 54%. During the observation period we found a gradual decrease in the use of IABP as well as a reduction in mortality.

[A centrifugal pump used as a support of left ventricular pumping function after extracorporeal circulation]. / Centrifugalpumpe anvendt til støtte af venstre hjerteventrikels pumpefunktion efter ekstrakorporal cirkulation.

The first Danish employment of a centrifugal pump for relief of the left ventricle after open heart surgery is presented. A man aged 72 years with three-vessel coronary arteriosclerosis was submitted to a coronary by-pass operation. At the conclusion of the operation, the pumping capacity of the heart was found to be so reduced that it was not possible to maintain an adequate minute-volume without support from a mechanical pump. The circulation in this patient was supported for four hours by means of an outflow catheter from the left atrium and an inflow catheter in the ascending aorta. After this, the patient's own heart could achieve the necessary minute-volume. The remainder of the postoperative course was uncomplicated.

Magnesium content of the human heart.

Although changes in the body's magnesium status have been linked to ischemic heart disease, sudden death and arrhythmia, there is as yet no recommended, established procedure for evaluation of magnesium homeostasis. We therefore explored the relationship between the magnesium content of the heart and that of serum, lymphocytes and skeletal muscle in 50 men undergoing cardiac surgery, using biopsies from the right auricula, right atrium and skeletal muscle and simultaneously drawn venous blood for measurement of lymphocyte and serum electrolyte concentration. Median magnesium values (mumol/g wet weight) were 7.42 (3.98-8.89) in skeletal muscle, 5.49 (3.44-7.66) in right auricula and 5.80 (2.60-7.53) in right atrium. The magnesium concentration in skeletal muscle was found to correlate with that in right auricula (r = 0.46, p less than 0.01) and right atrium (r = 0.43, p less than 0.01), whereas values in serum and lymphocytes showed no correlation with the heart's magnesium content. When myocardial biopsy is not available, skeletal muscle magnesium concentration seems to be the best predictor of the human myocardium's magnesium status.

Pancreaticogastrostomy for chronic pancreatitis.

Forty-five patients with painful chronic pancreatitis underwent side-to-side pancreaticogastrostomy. Correct diagnosis was ensured by endoscopic retrograde cholangiopancreatography, decreased exocrine pancreatic secretion, abdominal calcifications, and histologic verification. A main etiologic factor was alcohol abuse (84 percent of patients). At a median follow-up period of 3.8 years, good, fair, and poor results were achieved in 56, 23, and 21 percent of patients, respectively. The operative mortality rate was 4.4 percent. At follow-up, 16 of the patients were employed, weight was increased by a mean of 2.5 kg, and the use of opiates was significantly reduced. Poor results were significantly related to preoperative use of tranquilizers and postoperative alcohol consumption. Neither patency of the anastomosis nor the time of observation were related to the operative result. The 8-year cumulative survival rate was 83 percent.

Single or multiple doses of metronidazole and ampicillin in elective colorectal surgery. A randomized trial.

A randomized trial including 294 patients was performed to evaluate the prophylactic effect of single vs. multiple doses of antibiotics in elective colorectal surgery. All patients received 1.5 g metronidazole and 3.0 g ampicillin peroperatively and were randomized to: no further prophylactic antibiotic treatment, or ampicillin 1 g X 3 and metronidazole 0.5 g X 3 given intravenously during the second and third postoperative days. Deep wound infection was seen in 9/149 (6 percent) receiving a single dose and in 8/145 (6 percent) receiving multiple doses. No differences were found in the two groups between frequencies of anastomotic dehiscences, intra-abdominal abscesses, sepsis, and pulmonary infections. The two groups were similar according to distribution of sex, age, diagnosis, and type of surgery. A single peroperative dose of metronidazole and ampicillin is a simple and satisfactory antibiotic prophylaxis in elective colorectal surgery.

Rectal prolapse in infancy: conservative versus operative treatment.

In infancy there are two types of rectal prolapse. One type is less pronounced and intermittent. This type occurred in 9 out of 17 children referred for rectal prolapse and ceased after a few weeks' conservative treatment. The other type is a more pronounced prolapse occurring at nearly each defecation and lasting several weeks or months. These patients may need an operation, especially when ulceration of the mucosa occurs. In our patients, a Lockhart-Mummery operation was used successfully in all but one patient. No complications were observed. Though less extensive treatment, such as submucosal injection of sclerosing agents, is recommended to be the first method of choice because pathoanatomically the prolapse in infancy is frequently a prolapse of the mucosa, in patients where this therapy does not succeed, a Lockhart-Mummery operation may be an alternative.

Suprapubic bladder drainage in elective colorectal surgery.

Suprapubic bladder drainage was assessed in 399 patients, following surgery of the rectum and sigmoid colon. An Argyle-Ingram catheter no. 16 French was inserted after the laparotomy incision had been made. The bladder was drained continuously for 24 hours, after which the catheter was closed and reopened every 6 hours for 10 minutes. The catheter was removed when the postvoided volume became less than 50 ml on each of two subsequent measurements. Abdominoperineal excision required the longest drainage period. Urethral catheterization became necessary in 13 men and six women because of persistent or recurrent urinary retention. Failures of suprapubic drainage made urethral catheterization necessary in 17 of 31 patients. Uroperitoneum, due to leakage from the bladder after removal of the suprapubic catheter, was seen in one patient with infravesical obstruction and bladder diverticula. The patient recovered after relaparotomy and suture of the bladder. Suprapubic drainage is recommended because it permits spontaneous voiding. Urethral instrumentation is avoided in most cases. Residual volume can be measured without urethral catheterization. Complications are few, and discomfort to the patient is seen in no more than 1 percent.

Rectal prolapse and anal incontinence treated with a modified Roscoe Graham operation.

The results of abdominal mobilization of the rectum and repair of the pelvic floor behind the anorectal junction are reported in 23 patients with rectal prolapse, being accompanied by some form of anal incontinence in 12. Within 20 months, on the average, three patients had recurrent prolapse. Two thirds of the patients with incontinence for solid and/or fluid feces were cured for prolapse as well as incontinence. Seven became constipated, while 14 were fully satisfied. Seven of eight patients with a highly reduced tone of the external sphincter before surgery had a marked improvement after surgery. The results do not differ greatly from those after the suspension operation or repair of the pelvic floor in front of the rectum, despite being more physiologic, but suggest that simultaneous suspension and abdominal repair of the pelvic floor may avoid the need for a secondary postanal repair from below in patients with persistent incontinence after suspension surgery. A controlled, randomized trial is advocated.

Enterocutaneous fistulization due to Actinomyces odontolyticus. Report of a case.

A case of abdominal actinomycosis originating from the sigmoid colon is presented. Actinomyces odontolyticus was isolated; it is a rarity, but should be suspected in the case of a palpable mass and several fistulas developing after a latent period of weeks to months following surgical or inflammatory trauma. The diagnosis is made by anaerobic cultivation. Primary treatment with large doses of penicillin for several weeks may be supplemented by surgery. The strain isolated in the present case was only moderately sensitive to penicillin and was successfully treated with erythromycin.

Two cases of malakoplakia of the prostate.

2 further cases of malakoplakia of the prostate are reported, so that a total of 23 cases have now been described. The histological picture, as well as the methods of staining for the demonstration of the pathognomonic Michealis-Gutmann bodies are reviewed. The presence of Escherichia coli as a possible factor in the etiology is discussed. A description is given of the symptoms and physical findings in cases of prostatic malakoplakia, and the differential diagnosis, with particular reference to cancer of the prostate, is reviewed. Histology alone can provide the correct diagnosis. Finally it is emphasized that malakoplakia can be treated with long-term antibiotic therapy.